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Effectiveness of interventions to improve the detection and treatment of osteoporosis in primary care settings: a systematic review and meta-analysis |
Laliberte MC, Perreault S, Jouini G, Shea BJ, Lalonde L |
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CRD summary The review concluded that multifaceted interventions that targeted high-risk patients and their primary care providers may improve the management of osteoporosis, but improvements were clinically modest, particularly for non-high-risk patients. The authors’ conclusions reflect the evidence presented but the small number of studies in the analysis means their reliability is uncertain. Authors' objectives To evaluate the effectiveness of primary care interventions to improve the detection and treatment of osteoporosis. Searching MEDLINE, EMBASE, PsycINFO, ERIC, EBM Reviews, CENTRAL, CINAHL and Current Contents were searched for articles in English or French from 1985 to 2009; search terms were reported. Websites including UMI ProQuest Digital Dissertations, the Canadian Institutes of Health Research website and proceedings of the International Osteoporosis Foundation World Conference from 2000 to 2008 were searched for grey literature. Reference lists of selected articles and reviewers were scanned for additional studies and corresponding authors of the studies contacted for additional information. Study selection Randomised controlled trials (RCTs), controlled clinical trials, quasi-randomised trials, controlled before and after studies and interrupted time series studies that evaluated primary care interventions aimed at improving the detection and treatment of osteoporosis were eligible for inclusion. Eligible comparison groups were usual care or a control intervention on a topic other than osteoporosis. To be eligible, studies had to include people at risk or high risk of osteoporosis. At risk was defined as women 65 years or over, men 70 years or over and men and women 50 years or over with at least one major risk factor for osteoporosis. High risk was defined as men or women using oral glucocorticoids or with previous fragility fractures. Outcomes of interest included incidence of bone mineral density testing, osteoporosis treatment initiation and fractures. Eligible studies had to include patient follow-up of at least three months. Interventions that were a component of a general intervention for chronic diseases were excluded. Studies of interventions that evaluated efficacy of medications, exercise and physical activity programmes, or that assessed adherence were also excluded. Most of the included interventions were multifaceted and involved patient education material, patient notification, physician notification or physician education and patient counselling. Over half of the studies included patients at high risk for osteoporosis or fractures. Over half the studies included both men and women, the remainder included women only. Most participants had a previous fragility fracture. All the studies were conducted in Canada and the USA. Two reviewers independently selected each study for inclusion. Disagreements were resolved through discussion. Assessment of study quality Study quality was assessed using modified criteria from the Cochrane Risk of Bias assessment tool and the Cochrane EPOC group quality check list and included the assessment of methods of allocation sequence generation and concealment, completeness of follow-up, blinding, baseline outcome measurements and their reliability, potential for contamination, unit of analysis error, participant baseline characteristics, incomplete outcome data and the possibility of other risks of bias. Two reviewers independently assessed quality. Any disagreements were resolved through discussion or a third reviewer. Data extraction Data were extracted and stratified into patients at risk or at high risk of osteoporosis based on intention-to-treat analysis. Where a study had more than one intervention group, the group with the most intensive intervention was used for analysis. Data for relevant outcomes were used to calculate the risk difference (RD) and 95% confidence intervals (CIs). For cluster randomised controlled studies adjustment was made for design effect. Two reviewers independently extracted data. Methods of synthesis Pooled risk differences and 95% confidence intervals were calculated using a random-effects model. Heterogeneity was assessed using Χ² and Ι². Subgroup analyses were conducted to examine the impact of risk of bias and study design. Results of the review Thirteen studies were included in the review but only eight were included in the analysis (16,634 participants): three patient-randomised controlled trials (RCTs), four cluster-RCTs and one quasi-RCT. The median proportion of applicable criteria met for risk of bias assessment across all 13 studies was 73% (range 30 to 90%). Follow-up duration ranged from four to 16 months. Pooled results found a significant increase for high-risk patients in the incidence of osteoporosis treatment initiation following interventions (RD 20%, 95% CI 7 to 33%; four studies; Ι²=32%) and in the incidence of high-risk bone mineral density testing and/or initiating osteoporosis treatment following interventions (RD 40%, 95% CI 32% to 48%; two studies; Ι²=0%). Subgroup analyses did not significantly change results for any outcomes. The absolute difference was higher in intervention groups compared with control groups for the incidence of high-risk bone mineral density testing for high-risk patients (range 22 to 51%; four studies), at-risk patients (18%, one study) and for studies targeting both at-risk and high-risk patients (4% to 12%; two studies); for the incidence of osteoporosis treatment initiation for high-risk patients (18% to 29%; three studies), at-risk patients (4%; one study), and for both at-risk and high-risk patients (2%; one study). Other results were reported. Authors' conclusions Multifaceted interventions targeting high-risk patients and their primary care providers may improve the management of osteoporosis, but improvements were often clinically modest particularly for non-high-risk patients. CRD commentary The review question was clear with detailed inclusion criteria for study design, intervention and participants. Several relevant sources were searched and efforts were made to locate unpublished studies. The authors noted that only published studies were included in the review and this, together with some language restrictions, meant that some studies may have been missed. Study quality was assessed and the results were adequately reported. Appropriate methods to reduce reviewer error and bias were undertaken throughout the review process. Just over half of the studies included data on relevant outcomes and it was unclear why the remaining studies were excluded from the analysis. There were only a few studies reported for some outcomes. Less than half the studies could be combined in the meta-analysis. All the studies were conducted in Canada and the USA and the results may not be generalisable to other populations and settings. The authors’ conclusions reflects the evidence presented but the reliability of the conclusions is uncertain as they are based on only a small sub-set of included studies. Implications of the review for practice and research Practice: The authors did not state any implications for practice. Research: The authors stated that further research was needed to develop and evaluate more intensive multidisciplinary interventions that targeted health professionals such as community pharmacists, physician assistants and nurse practitioners as well as primary care physicians, to ensure continuity of care. Funding Candian Institutes of Health Research, Osteoporosis Canada; Fonds de recherché en santé du Quebec (FRSQ). Bibliographic details Laliberte MC, Perreault S, Jouini G, Shea BJ, Lalonde L. Effectiveness of interventions to improve the detection and treatment of osteoporosis in primary care settings: a systematic review and meta-analysis. Osteoporosis International 2011; 22(11): 2743-2768 Indexing Status Subject indexing assigned by CRD MeSH Humans; Mass Screening; Osteoporosis /diagnosis /therapy; Primary Health Care AccessionNumber 12011007321 Date bibliographic record published 17/02/2012 Date abstract record published 03/07/2012 Record Status This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn. |
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